Nursing care plan for non healing wound

Introduction

A non-healing wound is defined as a wound that is not showing any progress towards healing in three weeks. It is essential to assess the wounds and then develop a comprehensive nursing care plan to assist in healing the wound. This article explains the components of a well-structured nursing care plan for non-healing wounds.

Assessment

The assessment is a critical step for better identifying the suitable treatment for a non-healing wound. It includes aspects such as the:

• Risk Factors – this involves assessing the factors which may be hindering the healing process like use of tobacco, high blood sugar, drug reactions, poor nutrition, age and ulcer etiology (Chronic Venous Insufficiency, Malnutrition, Pressure Ulcers, etc.).
• Pathophysiology – it refers to identifying why the wound has not healed; for example, if inflammation and ischemia is present near the wound.
• Stage – the assessment includes determining the stage of the wound (acute or chronic).
• Severity – the severity of the wound (malodorous, eschar, necrotic tissue, etc.) also needs to be evaluated.

Nursing Diagnosis

After assessing the patient’s overall health, health history, and the wound itself, the nurse should come up with a nursing diagnosis. Potential nursing diagnoses for non-healing wounds include:

• Ineffective Tissue Perfusion – when the oxygen delivery to the cells gets affected due to an obstruction, resulting in poor wound healing.
• Risk for Infection – the presence of necrotic tissue increases the risk of wound infection.
• Impaired Skin Integrity – related to skin inflammatory processes caused by bacteria or environmental agents in the wound area.
• Pain – related to persistent inflammation and tissue damage/destruction.

Outcomes

The outcomes should be specified by goal statements in measurable terms. For example, the patient will have pain relief and the wound will heal after x number of days with minimal complications. The outcomes should also address factors such as risk factors, stage, and the severity of the wound.

Interventions

The interventions are designed to provide optimum care and promote wound healing. Such interventions may involve:

• Resolution of risk factors
• Dressing changes with proper wound management
• Wound debridement as recommended by the physician
• Fostering fluid balance
• Encouraging exercise and mobility
• Administration of antibiotics

Rationales

Rationales explain why certain interventions are used for a particular condition. Rationales for non-healing wound care include:

• The resolution of risk factors can significantly increase the chances of wound healing.
• Frequent dressing changes help reduce inflammation, minimize scarring, and discourage bacterial colonization.
• Debridement relieves pressure, reduces pain, minimizes inflammation, and removes damaged tissue.
• Exercise and mobility promote circulation to the wound area and stimulate healing.
• Antibiotics effectively reduce the risk of infection.

Evaluation

The evaluation process evaluates if the chosen interventions are working as intended, and makes modifications if necessary. Possible evaluation options are:

• Observe patient’s general condition
• Comparison of wound assessments
• Measurement techniques
• Questionnaires
• Vital signs monitoring

Conclusion

A comprehensive and well-structured care plan is important for nurses to better manage non-healing wounds. The care plan must be patient-centric and include risk factors, pathophysiology, stage, severity and goals of the patient. Furthermore, appropriate interventions and rationales should be included to assist with the effective management of the non-healing wound. Additionally, frequent evaluations should be part of the care plan to look out for any recovery delays.

FAQs

1. What is a nurse's role in the care of a non-healing wound?
   • Nurses play a critical role in the care and management of non-healing wounds. Their responsibilities include conducting assessments, coming up with nursing diagnoses and formulating suitable care plans. Additionally, they should educate the patient through counselling as well as monitor their progress through frequent evaluation.
2. What interventions are used in the care of a non-healing wound?
   • Interventions commonly used in nursing care plans for non-healing wounds include resolution of risk factors, dressing changes, wound debridement, fostering fluid balance, encouraging exercise and mobility, and antibiotics administration.
3. What are the goals of a nursing care plan for a non-healing wound?
   • The goal of a nursing care plan for a non-healing wound is to ensure rapid healing with minimal complications. More specifically, it mainly focuses on relieving pain, promoting healing, preventing infection, and restoring skin integrity.
4. What methods can be used for the evaluation of a non-healing wound?
   • Possible methods for evaluating a non-healing wound include observing patient’s general condition, comparing wound assessments, using measurement techniques, questionnaires, and vital signs monitoring.
5. Why is it recommended to involve a patient's family members in the care plan?
   • It is considered important to involve family members in the care of non-healing wounds since they can provide important information and help monitor progress more effectively.